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Tactics for Reducing AMA Discharges

Posted on Wed, Jul 27, 2016
Tactics for Reducing AMA Discharges

By Adam Corley, MD, FACEP, FAAEM
 
A few weeks ago, I cared for a very nice woman who was suffering from a mild cerebral vascular accident (CVA). Her symptoms of weakness in her arm and leg and mildly slurred speech had been going on for more than a few hours, so I didn’t consider her a TPA candidate.
 
I ordered all of the usual treatment and tests for CVA, including a CT of the brain, which confirmed the diagnosis. I went back in to re-examine her, discuss my findings and recommendations, and to let her know that she would need to be admitted to the hospital for additional testing and to see a neurologist.
 
Her exam was unchanged and she listened patiently as I discussed her test results and my recommendations. She asked several questions to better understand her diagnosis and prognosis and she asked me what would happen if she wasn’t admitted to the hospital. I went over the details of my proposed hospitalization, the tests that we would run and the importance of seeing a neurologist.
 
My patient then told me that she would not be able to stay in the hospital. She was the only caregiver for her sick husband and felt that she could get all of the necessary testing as an outpatient. We discussed the risks, benefits and alternatives to hospitalization and discharge, which she seemed to understand. I made a few phone calls to make sure that she could have easy access to the necessary outpatient testing, treatments and specialists, wrote her prescriptions, and encouraged her to return if her condition worsened or if she changed her mind. She completed the necessary paperwork and then I discharged her home from the ER with a diagnosis of acute ischemic CVA.
 
Patients like this who are discharged against medical advice (AMA) make up 1 to 2 percent of all medical admissions and represent unique ethical, legal, financial and operational challenges in healthcare.
 
A 2007 study published in the Journal of Allergy and Clinical Immunology showed that patients with asthma who leave AMA are four times more likely to return to the ER within 30 days and nearly three times more likely to require readmission to the hospital. A study in the International Journal of Clinical Practice concluded that the average length of stay for a readmission following AMA discharge was 2.4 days longer and cost 56 percent more.
 
Several studies have examined the demographic correlations for patients deciding to leave AMA. Substance abuse, lack of insurance, Medicaid and lower socioeconomic status tend to correlate with higher AMA rates.
 
Recently, I have noticed certain groups and hospital systems considering focusing on reducing AMA discharges as a quality measure. The thinking is that if we can reduce patients leaving AMA, they will receive the care necessary to properly treat their illness and probably save the patient, hospital, insurance company or government payer money at the same time. However, it is critically important to approach this issue in a careful and deliberate manner to preserve patient liberty.
 
Patients who are competent to manage their own healthcare and understand the treatment recommendations presented to them should have the autonomy to make decisions that they feel are in their own best interest. Even the sagest medical advice may not be right for some patients or in certain situations.
 
As we work to improve the quality of healthcare in American and continue to focus on population health, it is critically important to maintain patient autonomy and the sanctity of the doctor-patient relationship. Patients should be free to choose the right treatment course for them or to forgo treatment all together if that is their choice. We must avoid the temptation to apply a one-size-fits-all mentality to the delivery of healthcare.
 
Excellent physician communication, systems that reduce barriers to healthcare delivery, individualized solutions to improve patient experience and a flexible approach to meeting patient needs are all excellent tactics to reduce AMA discharges. However, a heavy-handed approach to pressure patients to comply with recommended treatment would be wrong. We should respect patient autonomy and encourage people to make their own healthcare decisions — even if we disagree with them. 


 
Dr. Adam Corley is a practicing emergency physician with more than 10 years of clinical and leadership experience. Dr. Corley serves as Executive Vice President for EmCare’s West Division. He also serves as the medical director for several EMS services and the Anderson County Texas Sheriff’s Department. Dr. Corley lectures and writes on a variety of topics, including decision science and behavioral economics, management of disruptive behavior in healthcare, conflict resolution and healthcare leadership.
 
 

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10 Rules of Engagement for Change Management

Posted on Tue, Mar 24, 2015
10 Rules of Engagement for Change Management

The process of organizational change is challenging. To be successful, organization leaders must take a disciplined approach to engaging the team. 

 
Rule #1: Start early (Don’t plan the change then ask for buy-in. Start when you know change is needed). 
 
Being reactive in the healthcare setting is usually the norm. It is imperative to be able to anticipate challenges and use prior data to your advantage (volume, surge, staffing etc.). When deciding on projects for changes within the healthcare setting, frequently clues to what needs change are right in front of you.  Anticipate changes as a team. For example, it is a certainty that E.D. volumes will increase when the flu season hits.  Do not wait until the last minute to involve people in planning for how to deal with those surges.  Use the data from the prior year to estimate what the volumes may be and discuss what staffing will be needed to take care of those patients.  Planning for change should be an ongoing process so that your team is prepared for expected changes.  For example, the staffing plan for flu season should be developed in the months when flu is not prevalent, rather than when the eventual annual epidemic is in full swing.
 

Rule #2: Go deep and wide (Involve people at all levels and in all departments.)
 
Bench strength is key. Sometimes the people on the front line will have the best ideas for how to solve issues or implement changes. In addition, make sure that you are using a multidisciplinary approach to projects. Almost never does a problem affect one department or unit.  No longer is throughput just an E.D. problem, and the most effective and efficient solutions have come from teams that are made of members from all areas of the facility.  Ancillary services, such as lab, radiology and housekeeping are key stakeholders in the overall throughput of the patients.  Most of the time, there are solutions from other departments that can have a significant impact on the project.
 
Rule #3: Start with a strategy (This is your plan.  Having a plan does not ensure you will reach your goal, but not having one ensures your failure.)
 
Make sure that you have a clear end goal in place and a well-thought plan to get there. Be able to use history, evidence, advisors and other resources around you to explore theories, options and ideas. Especially in healthcare, there are many references for past successes that can aid in reaching current goals. Having a multidisciplinary team can also help develop an operative strategy. Harness the strengths of the team to ensure a successful project. 
 
Rule #4: Communicate with clarity and precision (Generalities seldom make an impression.  Provide specifics and show examples of how the strategy will impact individuals. Have people consider what they need to change about their daily routine.)
 
Being able to effectively share the plan and goal is epic in the success of any project. Make sure that there is both written and verbal communication of the process with all stakeholders.  Ensure that communication happens early in the process to allow feedback and strong participation from the team.  Summaries of the meetings and action items should be provided and updated during the process and available for review at each of the meetings.  Meeting notes are key when utilizing sub-groups and being able to share progress with the entire team. 
 
 
Rule #5: Divide and conquer (Segment the troops. Give each team a segment of the project.)  
 
There is great value in defining each step of the plan to reach the end goal.  It can also helpful to break down the process into manageable pieces.  These different parts of the process can be delegated to sub-groups which are assigned by specialties or expertise of the group.  When the smaller assignments are completed, these wins can also be celebrated by the team. 
 
 
Rule #6: Choose leaders wisely (Rank does not have to be the deciding factor in change management.  Informal leaders or a person with a mission can be highly effective. Don’t be afraid to give people an opportunity to learn more about leading.)
 
It is imperative to identify and groom future leaders, especially in healthcare. The early investment in our successors can help guide their growth as leaders.  It can also foster free thinking if the leader of a project is not the most senior leader. The remainder of the team can frequently feel more comfortable and be more forthcoming with suggestions.  They may be more engaged in brainstorming solutions when they see that opinions are being solicited and valued and not simply mandated from administration. You may find that "diamond in the rough" when you are able to engage a young, up-and-coming staff member who may not even know he/she is up to the challenge. Frequently, we rely on "tried and true” team leaders. We need to remember that though these leaders are almost 100 percent successful, we run the risk of contributing to burnout or overload. This altruistic leader will take on "just one more project or task" for the greater good every time without regard for themselves, especially in nursing or healthcare. 


Rule #7: Award Ownership (Give project leaders ownership of the outcome including responsibility, accountability and authority.)
 
Too often projects are “everybody’s goal” making it too easy to point fingers at everyone else.  Give leaders the opportunity to succeed or fail.  Either way, the leader will benefit in the long run. Authority may include a budget and the ability to replace a team member.

 
Rule #8:  Move the line forward one step at a time (No matter how gigantic the project/change, the method of getting there is the same. Take one step at a time.)
 
Baby steps, especially in healthcare change, usually reap the greatest rewards. The problem that requires change didn’t happen all at once and usually is multifaceted. Being able to break down the project into manageable chunks usually leads to interesting dialogue and positive outcomes. You also have the opportunity to tap into the expertise of the team and possibly identify future leaders by soliciting feedback from all.  This is also where the team can celebrate the small wins and completions of action items throughout the process. 


Rule #9:  Evaluate and measure progress (What does success look like? What metrics are available to track success?)
 
Luckily in healthcare we are able to mine a wealth of metrics and data. Many of the projects are sparked by an unfavorable metric or data point such as patient satisfaction or throughput times.  At most hospitals, there is the ability to obtain data for almost every type of project.  Throughput is one of the processes that changes frequently. Not only can throughput be evaluated by looking at the prior data, but it can also be monitored for success by using the same data.  A key to success is being able to share this data with the team and the front line staff that it directly impacts in order to foster change.  For example, it has been shown that there can be improvement simply by sharing individual specific performance with providers.  Most do not want to be at the bottom and most will self-correct somewhat simply by being able to see their own scores.  There is also value in the statement “what gets measured gets results.”
 

Rule #10: Celebrate victories. (Praise is addictive.  People will want more.)
 
Celebration is paramount to the overall success of any change. Especially in healthcare when most are programmed to deal with illness and the diagnosis of problems, it is important to be able to celebrate when things go well!  Earlier I mentioned "baby steps." It is monumental to celebrate those small successes. Such celebration fuels the remainder of the project. For example, celebrating incremental increases in patient satisfaction scores. When an organization is in the bottom percentile, celebrating a shift in the right direction can frequently motivate the staff to continue their efforts and reinforce positive behaviors that lead to continued improvement. 




ABOUT THE AUTHOR 

Ginger joined EmCare in 2013 as a Divisional Director of Clinical Services for the South Division with the strong belief that she could continue to make positive changes within healthcare by helping others focus on quality, excellence and the overall patient experience. Ginger Wirth regards her role as Director of Clinical Services as the ideal opportunity to partner with nursing, physician and facility leaders to make positive changes to the entire patient care experience. Her 20+ year nursing career has been dedicated to quality and excellence, promoting overall positive outcomes and safety for patients. 

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